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Requested Illustration:

1. PLEASE LIST THE DATE OF THE FIRST DIAGNOSIS:

2. WAS A BIOPSY DONE? Yes No

3. PLEASE NOTE STAGE DIAGNOSED

4. HOW WAS THE SARCOID TREATED?
PREDNISONE
NO TREATMENT
DATE TREATMENT WAS COMPLETED

5. IS THE CLIENT ON ANY MEDICATIONS FOR THE IMPAIRMENT? Yes No
IF YES, PLEASE DETAIL

6. PLEASE NOTE WHICH ORGANS WERE INVOLVED: (CHECK ANY THAT APPLY)
LUNG
HEART
LIVER
SPLEEN
EYES
KIDNEY
CENTRAL NERVOUS SYSTEM
SKIN
LYMPH NODES

7. PLEASE GIVE RESULTS OF THE MOST RECENT PULMONARY FUNCTION TEST:
PVC    FEV1

8. HAS THERE BEEN ANY EVIDENCE OF PROGRESSION? Yes No
IF YES, PLEASE DETAIL

9. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT? Yes No
IF YES, PLEASE DETAIL

10. CLIENT'S OCCUPATION FULL TIME PART TIME

11. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK? Yes No
IF YES, PLEASE DETAIL

12. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: